NUR 202/NUR202 Final Exam V2 | Maternal-
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who is at 34 weeks of gestation and reports sudden, dark red
vaginal bleeding. The nurse notes that the patient’s abdomen is rigid and painful to the
touch. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Hydatidiform mole
D. Cervical incompetence
Correct Answer: B
Explanation: Abruptio placentae is characterized by painful vaginal bleeding and a board-
like, tender abdomen. Unlike placenta previa, which is usually painless, this condition
involves the premature separation of the placenta from the uterine wall. The nurse must
prioritize monitoring for maternal shock and fetal distress in this emergency situation.
2. A nurse is reviewing the GTPAL system for a client who is pregnant for the fourth time. She
has one child born at 39 weeks, one born at 32 weeks, and had one spontaneous abortion at
10 weeks. How should the nurse document her status?
A. G4, T2, P1, A0, L2
B. G3, T2, P0, A1, L2
,C. G4, T1, P1, A1, L2
D. G3, T1, P1, A1, L1
Correct Answer: C
Explanation: The client is currently pregnant (G4) and has one term birth at 39 weeks
(T1). She has one preterm birth at 32 weeks (P1) and one spontaneous abortion (A1). This
results in two living children (L2) because the current pregnancy is not yet counted in the
living category.
3. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. Which of the following actions is the nurse’s priority?
A. Turn the client onto her side
B. Administer oxygen via nonrebreather mask
C. Increase the rate of the IV infusion
D. Notify the provider immediately
Correct Answer: A
Explanation: Repositioning the client to a side-lying position is the first action to improve
placental perfusion and resolve fetal hypoxia. Late decelerations often indicate
uteroplacental insufficiency, and shifting maternal weight off the vena cava can improve
cardiac output. While oxygen and IV fluids are important, maternal positioning is the
quickest bedside intervention.
, 4. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus is boggy
and displaced to the right of the midline. Which of the following is the most likely cause?
A. Uterine atony
B. Retained placental fragments
C. Endometritis
D. Bladder distension
Correct Answer: D
Explanation: A distended bladder can push the uterus up and to the right, preventing it
from contracting effectively. This displacement increases the risk of uterine atony and
subsequent postpartum hemorrhage. The nurse should encourage the client to void or
perform catheterization if necessary to allow the fundus to return to the midline.
5. A nurse is providing discharge teaching to the mother of a newborn. Which of the following
instructions should the nurse include regarding umbilical cord care?
A. Apply petroleum jelly to the cord daily
B. Clean the cord with alcohol at every diaper change
C. Keep the cord stump dry and outside the diaper
D. Pull the cord gently if it is hanging by a thread
Correct Answer: C
Newborn Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client who is at 34 weeks of gestation and reports sudden, dark red
vaginal bleeding. The nurse notes that the patient’s abdomen is rigid and painful to the
touch. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Hydatidiform mole
D. Cervical incompetence
Correct Answer: B
Explanation: Abruptio placentae is characterized by painful vaginal bleeding and a board-
like, tender abdomen. Unlike placenta previa, which is usually painless, this condition
involves the premature separation of the placenta from the uterine wall. The nurse must
prioritize monitoring for maternal shock and fetal distress in this emergency situation.
2. A nurse is reviewing the GTPAL system for a client who is pregnant for the fourth time. She
has one child born at 39 weeks, one born at 32 weeks, and had one spontaneous abortion at
10 weeks. How should the nurse document her status?
A. G4, T2, P1, A0, L2
B. G3, T2, P0, A1, L2
,C. G4, T1, P1, A1, L2
D. G3, T1, P1, A1, L1
Correct Answer: C
Explanation: The client is currently pregnant (G4) and has one term birth at 39 weeks
(T1). She has one preterm birth at 32 weeks (P1) and one spontaneous abortion (A1). This
results in two living children (L2) because the current pregnancy is not yet counted in the
living category.
3. A nurse is caring for a client in the first stage of labor and notices late decelerations on the
fetal heart rate monitor. Which of the following actions is the nurse’s priority?
A. Turn the client onto her side
B. Administer oxygen via nonrebreather mask
C. Increase the rate of the IV infusion
D. Notify the provider immediately
Correct Answer: A
Explanation: Repositioning the client to a side-lying position is the first action to improve
placental perfusion and resolve fetal hypoxia. Late decelerations often indicate
uteroplacental insufficiency, and shifting maternal weight off the vena cava can improve
cardiac output. While oxygen and IV fluids are important, maternal positioning is the
quickest bedside intervention.
, 4. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus is boggy
and displaced to the right of the midline. Which of the following is the most likely cause?
A. Uterine atony
B. Retained placental fragments
C. Endometritis
D. Bladder distension
Correct Answer: D
Explanation: A distended bladder can push the uterus up and to the right, preventing it
from contracting effectively. This displacement increases the risk of uterine atony and
subsequent postpartum hemorrhage. The nurse should encourage the client to void or
perform catheterization if necessary to allow the fundus to return to the midline.
5. A nurse is providing discharge teaching to the mother of a newborn. Which of the following
instructions should the nurse include regarding umbilical cord care?
A. Apply petroleum jelly to the cord daily
B. Clean the cord with alcohol at every diaper change
C. Keep the cord stump dry and outside the diaper
D. Pull the cord gently if it is hanging by a thread
Correct Answer: C
